ONCOLOGY Vol 27 No 2

To place responsibility for rationing chemotherapeutics on the oncologist not only increases his or her emotional burden, but it also strains the doctor-patient relationship. We should not allow oncologists to become bedside healthcare rationers simply because no one else wants to do the job.

Oncologists would be well advised to consider their obligations to the patient, as well as other stakeholders, and be prepared to resolve potential conflicts that go beyond the focus of their clinical training.

The prospect of even more compressed radiotherapy options for women requiring adjuvant breast radiotherapy is exciting. However, we urge readers to be cautious in their interpretation of the current intraoperative literature as they implement their programs.

Due to the fact that we do not have mature long-term data regarding efficacy, we are still several years away from declaring IORT to be a viable alternative to the current standard of care in patients with early-stage breast cancer.

Further prospective clinical trials in very elderly patients with DLBCL are clearly needed. Complementing the growing need for such trials, an evolving clinical trial infrastructure, geriatric oncology support, and novel therapeutics are making such studies feasible in the current era.

Patients should ideally undergo very thoughtful evaluation with tools such as the comprehensive geriatric assessment or something similar that will give the treating physician the best estimate of therapy tolerance. Once therapy is initiated, very frequent monitoring is useful for providing early support of toxicity and for most promptly and effectively informing appropriate dose adjustments to ensure optimal dosing.

Elderly patients may have several such comorbidities, but their impact on normal life is minimal-and so most of these patients may receive a curative treatment such as R-CHOP. Very elderly patients have more comorbidities with greater impact, with the result that some of their vital organs exhibit functional deficiency.

In this review, we critically analyze clinical trials that were specifically designed for the very elderly, and we discuss the challenges encountered by investigators who are conducting studies in this patient population. We conclude by proposing an algorithm to help clinicians determine the optimal therapeutic strategy for treatment of DLBCL in very elderly patients.

With many centers seeking to adopt IORT, there are licensing, proctoring, staffing, technical support, and reimbursement issues that need to be considered. We have reviewed the current international experience and describe one community cancer center’s experience with initiating an IORT breast cancer program.

It is hard to realize that an elderly patient's visit to you is likely the only trip outside his or her apartment for the week and the only contact with someone other than family or an aide. Doctor visits sometimes become the elderly's primary contact with the larger world.

Costs of care continue to rise; new cancer drugs are more expensive than ever before, and more patients are being treated with these drugs. While patients and claims datasets consistently report an association between financial burden and quality of care, the impact on traditional disease-related outcomes-survival, for example-have not been assessed.

In this article, we have chosen to focus on three ethical challenges that we believe practicing oncologists might commonly encounter with their patients. The ethical dilemmas are presented in a case-based approach in the hope of better joining the ethical theory to clinical practice.